Migrated foreign body liver abscess: illustrative case report, systematic review, and proposed diagnostic algorithm.

Pyogenic liver abscess is a severe condition and a therapeutic challenge. Treatment failure may be due to an unrecognized ingested foreign body that migrated from the gastrointestinal tract. There has recently been a marked increase in the number of reported cases of this condition, but initial misdiagnosis as cryptogenic liver abscess still occurs in the majority of cases. We conducted the current study to characterize this entity and provide a diagnostic strategy applicable worldwide. To this end, data were collected from our case and from a systematic review that identified 59 well-described cases. Another systematic review identified series of cryptogenic-and Asian Klebsiella-liver abscess; these data were pooled and compared with the data from the cases of migrated foreign body liver abscess. The review points out the low diagnostic accuracy of history taking, modern imaging, and even surgical exploration. A fistula found through imaging procedures or endoscopy warrants surgical exploration. Findings suggestive of foreign body migration are symptoms of gastrointestinal perforation, computed tomography demonstration of a thickened gastrointestinal wall in continuity with the abscess, and adhesions seen during surgery. Treatment failure, left lobe location, unique location (that is, only 1 abscess location within the liver), and absence of underlying conditions also point to the diagnosis, as shown by comparison with the cryptogenic liver abscess series. This study demonstrates that migrated foreign body liver abscess is a specific entity, increasingly reported. It usually is not cured when unrecognized, and diagnosis is mainly delayed. This study provides what we consider the best available evidence for timely diagnosis with worldwide applicability. Increased awareness is required to treat this underestimated condition effectively, and further studies are needed.

The data treatment dependent variability of U-Pb zircon ages obtained using mono-collector, sector field, laser ablation ICP-MS

U-Pb dating of zircons by laser ablation inductively coupled plasma mass spectrometry (LA-ICPMS) is a widely used analytical technique in Earth Sciences. For U-Pb ages below 1 billion years (1 Ga), Pb-206/U-238 dates are usually used, showing the least bias by external parameters such as the presence of initial lead and its isotopic composition in the analysed mineral. Precision and accuracy of the Pb/U ratio are thus of highest importance in LA-ICPMS geochronology. We consider the evaluation of the statistical distribution of the sweep intensities based on goodness-of-fit tests in order to find a model probability distribution fitting the data to apply an appropriate formulation for the standard deviation. We then discuss three main methods to calculate the Pb/U intensity ratio and its uncertainty in the LA-ICPMS: (1) ratio-of-the-mean intensities method, (2) mean-of-the-intensity-ratios method and (3) intercept method. These methods apply different functions to the same raw intensity vs. time data to calculate the mean Pb/U intensity ratio. Thus, the calculated intensity ratio and its uncertainty depend on the method applied. We demonstrate that the accuracy and, conditionally, the precision of the ratio-of-the-mean intensities method are invariant to the intensity fluctuations and averaging related to the dwell time selection and off-line data transformation (averaging of several sweeps); we present a statistical approach how to calculate the uncertainty of this method for transient signals. We also show that the accuracy of methods (2) and (3) is influenced by the intensity fluctuations and averaging, and the extent of this influence can amount to tens of percentage points; we show that the uncertainty of these methods also depends on how the signal is averaged. Each of the above methods imposes requirements to the instrumentation. The ratio-of-the-mean intensities method is sufficiently accurate provided the laser induced fractionation between the beginning and the end of the signal is kept low and linear. We show, based on a comprehensive series of analyses with different ablation pit sizes, energy densities and repetition rates for a 193 nm ns-ablation system that such a fractionation behaviour requires using a low ablation speed (low energy density and low repetition rate). Overall, we conclude that the ratio-of-the-mean intensities method combined with low sampling rates is the most mathematically accurate among the existing data treatment methods for U-Pb zircon dating by sensitive sector field ICPMS.

Sensitivity to Change of the Ultrasound synovitis SONAR Score in RA Patients: Results of the Scqm Cohort

Background/Purpose: Since the end of 2009, an ultrasound scoring call SONAR has been implemented for RA patients as a routine tool in the SCQM registry (Swiss Clinical Quality Management registry for rheumatic diseases). A cross-sectional evaluation of patients with active disease and clinical remission according to the DAS28ESR and the novel ACR/EULAR remission criteria from 2010 clearly indicated a good correlational external validity of synovial pathologies with clinical disease activity in RA (2012 EULAR meeting. Objective: of this study was to evaluate the sensitivity to change of B-mode and Power-Doppler scores in a longitudinal perspective along with the changes in DAS28ESR in two consecutive visits among the patients included in the SCQM registry Methods: All patients who had at least two SONAR scores and simultaneous DAS28ESR evaluations between December 2009 and June 2012 were included in this study. The data came from 20 different operators working mostly in hospitals but also in private practices, who had received a previous teaching over 3 days in a reference center. The SONAR score includes a semi-quantitative B mode and Power-Doppler evaluation of 22 joints from 0 to 3, maximum 66 points for each score. The selection of these 22 joints was done in analogy to a 28 joint count and further restricted to joint regions with published standard ultrasound images. Both elbows and wrist joints were dynamically scanned from the dorsal and the knee joints from a longitudinal suprapatellar view in flexion and in joint extension. The bilateral evaluation of the second to fifth metacarpophalangeal and proximal interphalangeal joints was done from a palmar view in full extension, and the Power-Doppler scoring from a dorsal view with hand and finger position in best relaxation. Results: From the 657 RA patients with at least one score performed, 128 RA patients with 2 or more consultations of DAS28ESR, and a complete SONAR data set could be included. The mean (SD) time between the two evaluations was 9.6 months (54). The mean (SD) DAS28ESR was: 3.5 (1.3) at the first visit and was significantly lower (mean 3.0, SD.2.0, p:_0.0001) at the second visit. The mean (SD) of the total B mode was 12 (9.5) at baseline and 9.6 (7.6) at follow-up (p_0.0004). The Power-Doppler score at entry was 2.9 (5.7) and 1.9 (3.6), at the second visit, p _0.0001. The Pearson r correlation between change in DAS28ESR and the B mode was 0.44 (95% CI: 0.29, 0.57, p_ 0.0001),and 0.35 (95% CI: 0.16, 0.50, p _ 0.0002) for the Power-Doppler score,. Clinical relevant change in DAS (_1.1) was associated with a change of total B mode score _3 in 23/32 patients and a change a Doppler score _0.5 in 19/26. Conclusion: This study confirms that the SONAR score is sensitive to change and provides a complementary method of assessing RA disease activity to the DAS that could be very useful in daily practice.

Influence of CD4+/CD25+ regulatory T cells on atherogenesis in patients with end-stage kidney disease.

Atherosclerosis, which is influenced by both traditional and nontraditional cardiovascular risk factors and has been characterized as an inflammatory process, is considered to be the main cause of the elevated cardiovascular risk associated with chronic kidney disease. The inflammatory component of atherosclerosis can be separated into an innate immune response involving monocytes and macrophages that respond to the excessive uptake of lipoproteins and an adaptive immune response that involves antigen-specific T cells. Concurrent with the influx of immune cells to the site of atherosclerotic lesion, the role of the adaptive immune response gradually increases. One of those cells are represented by the CD4+/CD25+ Tregs, which play indispensable roles in the maintenance of natural self-tolerance and negative control of pathological, as well as physiological, immune responses. Altered self-antigens such as oxidized LDLs may induce the development of CD4+/CD25+ Tregs with atheroprotective properties. However, atherosclerosis may be promoted by an imbalance between regulatory and pathogenic immunity that may be represented by the low expression of the forkhead box transcription factor (Foxp3) in CD4+/CD25+ Tregs. Such a defect may break immunologic tolerance and alter both specific and bystander immune suppression, leading to exacerbation of plaque development. Patients with end-stage kidney disease (ESKD) display a cellular immune dysfunction and accelerated atherosclerosis. Uremic solutes that accumulate during ESKD may be involved in these processes. In patients with ESKD and especially in those that are chronically hemodialyzed, oxidative stress induced by oxidized LDLs may increase CD4+/CD25+ Treg sensitivity to Fas-mediated apoptosis as a consequence of specific dysregulation of IL-2 expression. This review will focus on the current state of knowledge regarding the influence of CD4+/CD25+ Tregs on atherogenesis in patients with ESKD, and the potential effect of statins on the circulating number and the functional properties of these cells.

Estudi de la zona de finalització més eficaç per guanyar el punt mitjançant l'atac de dreta en el tennis de taula

L’objectiu d’aquest estudi és determinar la zona més efectiva per guanyar el punt mitjançant l’atac de dreta en el tennis de taula. S’utilitza una adaptació del sistema d’anàlisi dels tres nivells d’habilitat, proposat pels acadèmics xinesos Wu i Li (1990) per tal de classificar els punts de la forma que ens permetin analitzar les zones de finalització i les formes com s’obtenen els punts. L’estudi analitza cinc partits dels sis millors jugadors del rànquing mundial de la ITTF. El resultat de l’estudi és que la zona de finalització més eficaç per obtenir el punt mitjançant l’atac de dreta és la zona 1 de la taula del rival.

Un programa psicosocial: programa psicoestimulatiu integral (P.P.I.) amb persones afectades de malaltia d' Alzheimer

L'any 2011 la malaltia d'Alzheimer es situava com la quarta causa de mort més freqüent amb un augment de fins a 11.907, més del doble de morts que l'any 2000 (INE). Aquestes dades demostren l'augment del número de persones que pateixen una demència a mesura que envelleixen i una de les explicacions és l'augment de l'esperança de vida. Per aquest motiu l'estudi de la qualitat de vida ha adquirit una gran importància des de la dècada dels 90. La qualitat de vida és un concepte especialment subjectiu pel fet que cada persona la viu segons la pròpia percepció de salut i benestar i el grau d'adaptació a l'entorn que l'envolta. Per aquest motiu es planteja un programa de psicoestimulació integral (PPI) centrat en les individualitats de cada persona: valors, interessos, història ocupacional..., des de la filosofia de la Teràpia Ocupacional. El projecte està elaborat mitjançant la metodologia qualitativa utilitzant l'enquesta en profunditat semi-estructurada per a realitzar les entrevistes i obtenir la informació principal a l'inici i al final del programa juntament amb tota la informació que s'obtingui de l'observació participant del dia a dia de cada un dels professionals per tal d'estudiar fins a quin punt aquesta atenció centrada en la persona contribueix a millorar la qualitat de vida de les persones afectades de Malaltia d'Alzheimer que reben tractaments no farmacològics com el proposat en aquest projecte. Com a tot estudi es poden trobar alguns factors condicionants com pot ser l'evolució pròpia de la malaltia amb les conseqüències negatives que això comporta i/o el número de participants que formen la mostra.

Ubiquitin Ligases of the N-End Rule Pathway: Assessment of Mutations in UBR1 That Cause the Johanson-Blizzard Syndrome.

Background: Johanson-Blizzard syndrome (JBS; OMIM 243800) is an autosomal recessive disorder that includes congenital exocrine pancreatic insufficiency, facial dysmorphism with the characteristic nasal wing hypoplasia, multiple malformations, and frequent mental retardation. Our previous work has shown that JBS is caused by mutations in human UBR1, which encodes one of the E3 ubiquitin ligases of the N-end rule pathway. The N-end rule relates the regulation of the in vivo half-life of a protein to the identity of its N-terminal residue. One class of degradation signals (degrons) recognized by UBR1 are destabilizing N-terminal residues of protein substrates.Methodology/Principal Findings: Most JBS-causing alterations of UBR1 are nonsense, frameshift or splice-site mutations that abolish UBR1 activity. We report here missense mutations of human UBR1 in patients with milder variants of JBS. These single-residue changes, including a previously reported missense mutation, involve positions in the RING-H2 and UBR domains of UBR1 that are conserved among eukaryotes. Taking advantage of this conservation, we constructed alleles of the yeast Saccharomyces cerevisiae UBR1 that were counterparts of missense JBS-UBR1 alleles. Among these yeast Ubr1 mutants, one of them (H160R) was inactive in yeast-based activity assays, the other one (Q1224E) had a detectable but weak activity, and the third one (V146L) exhibited a decreased but significant activity, in agreement with manifestations of JBS in the corresponding JBS patients.Conclusions/Significance: These results, made possible by modeling defects of a human ubiquitin ligase in its yeast counterpart, verified and confirmed the relevance of specific missense UBR1 alleles to JBS, and suggested that a residual activity of a missense allele is causally associated with milder variants of JBS.

Política i empresa, companyes de viatge La qüestió catalana Reportatge digital sobre l’empresariat català i l’encaix Catalunya- Espanya. Valoracions entorn el debat sobiranista

El debat sobiranista català està a l‟ordre del dia i actualment no passa desapercebut en cap mitjà de comunicació ni tampoc en el món polític, econòmic i empresarial. El fet d‟estar tan viva una temàtica així de delicada està ocasionant controvèrsies dins l‟empresariat català o que té la seva empresa ubicada a Catalunya perquè tot plegat provoca moltes incerteses, que són el pitjor enemic dels empresaris i dels negocis. Tanmateix, però, les informacions publicades o emeses venen marcades per les opinions polítiques i periodístiques, que es troben censurades en certa mesura perquè segueixen una determinada línia política i/o editorial. Per això s‟ha elaborat un reportatge digital focalitzat en l‟empresariat català i l‟encaix Catalunya-Espanya que pretén aportar noves valoracions entorn a aquest debat donant veu a empresaris i professionals, entre altres. La part teòrica de la memòria defineix els conceptes bàsics que són de forçat coneixement per realitzar una part pràctica que ha de ser entesa per qualsevol persona i que s‟ha de tractar amb la major objectivitat possible. Per això, el web http://laquestiocatalana.cat aporta un llenguatge planer i les eines bàsiques per donar a conèixer una matèria molt criticada per alguns sectors. A través d‟entrevistes a personatges rellevants, el web introdueix nous punts de vista sobre una qüestió marcada, a simple vista, per la preocupació d‟un possible boicot per part d‟Espanya. Però aquesta no sembla ser la principal inquietud dels entesos, i és que hi ha altres aspectes encara més alarmants que poden influir en l‟empresariat i que no són tractats per cap mitjà de comunicació convencional.

Generation of symmetric periodic orbits by a heteroclinic loop formed by two singular points and their invariant manifolds of dimension 1 and 2 in R3

In this paper we will find a continuous of periodic orbits passing near infinity for a class of polynomial vector fields in R3. We consider polynomial vector fields that are invariant under a symmetry with respect to a plane and that possess a “generalized heteroclinic loop” formed by two singular points e+ and e− at infinity and their invariant manifolds � and . � is an invariant manifold of dimension 1 formed by an orbit going from e− to e+, � is contained in R3 and is transversal to . is an invariant manifold of dimension 2 at infinity. In fact, is the 2–dimensional sphere at infinity in the Poincar´e compactification minus the singular points e+ and e−. The main tool for proving the existence of such periodic orbits is the construction of a Poincar´e map along the generalized heteroclinic loop together with the symmetry with respect to .

Equilibrium points and central configurations for the Lennard-Jones 2-and 3-body problems

Abstract. In this paper we study the relative equilibria and their stability for a system of three point particles moving under the action of a Lennard{Jones potential. A central con guration is a special position of the particles where the position and acceleration vectors of each particle are proportional, and the constant of proportionality is the same for all particles. Since the Lennard{Jones potential depends only on the mutual distances among the particles, it is invariant under rotations. In a rotating frame the orbits coming from central con gurations become equilibrium points, the relative equilibria. Due to the form of the potential, the relative equilibria depend on the size of the system, that is, depend strongly of the momentum of inertia I. In this work we characterize the relative equilibria, we nd the bifurcation values of I for which the number of relative equilibria is changing, we also analyze the stability of the relative equilibria.

Symmetric periodic orbits near a heteroclinic loop in R3 formed by two singular points, a semistable periodic orbit and their invariant manifolds

In this paper we consider C1 vector fields X in R3 having a “generalized heteroclinic loop” L which is topologically homeomorphic to the union of a 2–dimensional sphere S2 and a diameter connecting the north with the south pole. The north pole is an attractor on S2 and a repeller on . The equator of the sphere is a periodic orbit unstable in the north hemisphere and stable in the south one. The full space is topologically homeomorphic to the closed ball having as boundary the sphere S2. We also assume that the flow of X is invariant under a topological straight line symmetry on the equator plane of the ball. For each n ∈ N, by means of a convenient Poincar´e map, we prove the existence of infinitely many symmetric periodic orbits of X near L that gives n turns around L in a period. We also exhibit a class of polynomial vector fields of degree 4 in R3 satisfying this dynamics.

Symmetric periodic orbits near a heteroclinic loop formed by two singular points and their invariant manifolds of dimension 1 and 2

In this paper we consider vector fields in R3 that are invariant under a suitable symmetry and that posses a “generalized heteroclinic loop” L formed by two singular points (e+ and e −) and their invariant manifolds: one of dimension 2 (a sphere minus the points e+ and e −) and one of dimension 1 (the open diameter of the sphere having endpoints e+ and e −). In particular, we analyze the dynamics of the vector field near the heteroclinic loop L by means of a convenient Poincar´e map, and we prove the existence of infinitely many symmetric periodic orbits near L. We also study two families of vector fields satisfying this dynamics. The first one is a class of quadratic polynomial vector fields in R3, and the second one is the charged rhomboidal four body problem.

Needs, expectations, and concerns of medical students regarding end-of-life issues before the introduction of a mandatory undergraduate palliative care curriculum.

BACKGROUND: In the past, implementation of effective palliative care curricula has emerged as a priority in medical education. In order to gain insight into medical students' needs and expectations, we conducted a survey before mandatory palliative care education was introduced in our faculty. METHODS: Seven hundred nine students answered a questionnaire mainly consisting of numeric rating scales (0-10). RESULTS: Participants attributed a high importance to palliative care for their future professional life (mean, 7.51 ± 2.2). For most students, symptom control was crucial (7.72 ± 2.2). However, even higher importance was assigned to ethical and legal issues (8.16 ± 1.9). "Self-reflection regarding their own role as a physician caring for the terminally ill along with psychological support" was also regarded as highly important (7.25 ± 2.4). Most students were moderately concerned at the prospect of being confronted with suffering and death (5.13 ± 2.4). This emotional distress was rated significantly higher by female students (5.4 ± 2.4 versus 4.6 ± 2.4; p < 0.001). Seventeen percent of all students rated their distress as being 7 of 10 or higher, which indicates a considerable psychological strain in terms of dealing with end-of-life issues in the future. Professional or personal experience with terminally ill persons lowered these anxieties significantly (4.99 ± 2.34 versus 5.47 ± 2.5, p < 0.05). CONCLUSIONS: Medical students stated a remarkably high interest in learning palliative care competencies. Responding to their specific concerns and needs-especially with regard to the acquisition of emotional coping skills-may be key for the development of successful palliative care curricula.